Download Spay / Neuter Application - Hornell Area Humane Society

Hornell Area Humane Society
7649 Industrial Park Road
Hornell, NY 14843
607-324-1270 – Fax 607-324-5584
www.hornellanimalshelter.org
SPAY/NEUTER ASSISTANCE APPLICATION
APPLICANT INFORMATION
Please note that any part left incomplete could forfeit your application. Please make sure to provide a complete application as well as
the necessary documentation for proof of income and residency. Currently our spay/neuter assistance serves the Steuben, Allegany,
and Livingston County residents.
Full Name:
Phone:
Other:
Email:
State:
ZIP Code:
Current address:
City:
Own
Rent
County:
(Please circle)
INCOME
Please provide proof of the following that apply to income verification: (MUST BE SUBMITTED WITH APPLICATION)
Pay Stubs
Government Assistance
HEAP
SNAP
Retirement
Medicaid ID Card
Social Security Assistance
PETS INFORMATION
Name:
Species:
Age:
Dog
Cat
Sex:
Breed:
Weight:
Color:
How long have you had this pet?
Is your pet:
Indoors
Outdoors
Both
How did you hear about us?
Thank you for your interest in the low cost spay/neuter program. This program provides low cost
spay/neuter surgeries for low income pet owners’ who meet the residency and income guidelines.
The pet must be at least three months old at the time this application is submitted. Return this application
with the required documents and fees to the address above. Once the application, documents and fees
have been received, reviewed, and approved by HAHS, you will be notified to schedule an appointment
with us for your pet to be spayed or neutered.
WE ARE UNABLE TO BOARD ANIMALS THE NIGHT
BEFORE SURGERY. ANIMALS MUST BE BROUGHT IN
THE MORNING OF SURGERY.
CLINIC FEES
•
ALL FEES ARE TO BE PAID PRIOR TO SCHEDULING AN APPOINTMENT.
•
A $20 FEE WILL BE ASSESSED FOR COMPLETE CANCELATION OR LESS
THAN 24 HOUR NOTICE OF NEED TO RESCHEDULE APPOINTMENT.
MALE CAT NEUTER
$50
FEMALE CAT SPAY
$70
DOG UP TO 40 POUNDS
$100
DOGS 40-90 POUNDS
$125
SPAY/NEUTER ASSISTANCE APPLICATION
PRICES INCLUDE:
•
MINI PHYSICAL EXAM BY A LICENSED VETERINARIAN
•
NAIL TRIM
•
EAR CLEANING
•
SINGLE DOSE OF ANTIBIOTIC
•
SINGLE DOSE OF PAIN MEDICATION
•
RABIES VACCINE
•
MEDICATION FOR FLEAS, EAR MITES AND ROUND WORMS
ADDITIONAL FEES AND OPTIONAL SERVICES
PREGNANT CAT
$25
HERNIA REPAIR
$15
PREGNANT DOG <40 POUNDS
$25
PREGNANT DOG 40+ POUNDS
$50
CRYPTORCHID (MALE DOG OR CAT WITH ONE TESTICLE
$20
FELINE LEUK/AIDS TEST
$30
$25
MICROCHIP
ANY ADDITIONAL FEES ARE TO BE PAID WHEN ANIMAL IS PICKED UP
•
NO APPOINTMENT WILL BE MADE WITHOUT FEES BEING PAID.
•
WE ACCEPT CASH, CREDIT OR DEBIT CARDS. NO PERSONAL CHECKS.
•
PROOF OF INCOME ELIGIBILITY IS NEEDED PRIOR TO SCHEDULING
APPOINTMENT.
•
IF YOUR CAT IS NOT IN A PROPER ANIMAL CARRIER, A CARRIER WILL BE
PROVIDED FOR YOU AT A COST OF $5. NO ANIMAL WILL BE DISCHARGED
WITHOUT A PROPER ANIMAL CARRIER.
•
FOR SAFETY, ALL CATS MUST BE IN INDIVIDUAL CARRIERS. DO NOT
BRING MULTIPLE CATS IN SAME CARRIER.
•
DUE TO CURRENT CLINIC EQUIPMENT, WE ARE UNABLE TO ACCEPT
DOGS OVER 90 POUNDS OR DOGS 7 YEARS AND OLDER AS DETERMINED
BY A LICENSED VETERINARIAN.
•
SURGERY WILL NOT BE DONE IF ANIMAL IS PREGNANT, IN HEAT OR
LACTATING, AS DETERMINED BY A LICENSED VETERINARIAN.
Signature of applicant:
Staff Use Only:
Date:
Approved
Denied
Notes:
HornellAreaHumaneSociety 7649IndustrialParkRd,Hornell,NY14843
Wasyourpetadoptedfromus?
NameofAnimalatShelter
Date:______________Owner/Agentname:_____________________________________________________
Address:__________________________________________________________________________________
City:_________________________________________________State:____________Zipcode____________
Telephonenumber(whereyoucanbereachedimmediately):_______________________________________
Animalname:______________________________________Species(circle): dog
cat
Breed:______________________________Sex:__________Age:___________Color:__________________
Dateoflastvaccinations:Distempercombo:_______________ Rabies:_________________13year
Patientinformation–Pleasefillout:
Whattimedidyourpetlasthavefood/water?(Daybeforesurgery)Date:____________Time:___________
Howlonghaveyouhadthisanimal? ___________________________________________________________
Hasthispeteverhadpuppies/kittens?Ifyes,whenwasthelastlitter:________________________________
Isthereapossibilitythispethasbeenspayed/neuteredorcouldbepregnant?_________________________
Ifyouhaveafemalepet,whenwasthelasttimeshewasinheat?___________________________________
Hasthispeteverhadareactiontovaccinationsoranesthesia?______________________________________
Isyourpetonanymedications?Ifyes,listthem:_________________________________________________
Hasyouranimalbittenanyoneinthelast10days?________________________________________________
Hasthispetshownsignsofillnessinthelastweeksuchascoughing,sneezing,vomiting,diarrhea,seizures,or
beendiagnosedwithanycontagiousorlifethreateningdisease(s)orcongenitaldisease(s)suchasaheart
murmur?Ifyes,listthem:___________________________________________________________________
Clinicuseonly
Surg.Date:________Weight:________Temp:________Pulse:________Resp:________
PhysicalExamnotes:__________________________________________________________________________
___________________________________________________________________________________________
Anesthesia:_________________________________________________________________________________
Painmed:_____________________________Starttime:___________________Endtime:_________________
Surgerynotes:_____________________________________________________________________
CONSENTFORMEDICALPROCEDURE(S)–PLEASEREAD,INITIALANDSIGN
Westronglyrecommendyourpetvisityourregularveterinarianforathoroughphysicalexam,todiscuss
yourpet’scare,andtohaveallrecommendedtestingperformedpriortosurgery.Ourmedicalstaffwill
examineyourpetpriortosurgeryhoweverwestillrecommendfollowingtherecommendationsofyour
regularveterinarian.Bysigningthisformyouareacknowledgingthatyouhaveeitherhadyourpet
examinedandtestedasrecommendedpriortosurgery,orthatyouarewaivingtherighttodoso,andboth
acknowledgethatyouranimalmaybeatincreasedriskofcontractingdiseaseoroccurringillnessordeath
duetoanesthesiaorthesurgicalormedicalproceduresandthatyouunderstandandaccepttheserisksand
willnotholdthestaffassociatedwiththeHornellAreaHumaneSocietyliableforsuchoutcomes.
__________I,beingoflegalage(18)andlawfullyauthorizedtomakedecisionsforthisanimalauthorizeand
givemyconsenttotheHornellAreaHumaneSocietyanditsagentstoreceive,transport,prescribefor,treat,
and/orperformsterilizationsurgeryandvaccinationtothisanimal.
__________Iunderstandthatmoderntechniqueswillbeusedandtrainedstaffwillcareformyanimal,and
reasonableprecautionswillbeusedagainstinjury,escape,illnessanddeathortheanimal.Itisthoroughly
understoodbymethattheHornellAreaHumaneSociety,itsstaff,volunteers,andagentswillnotbeheld
liableorresponsibleinanymannerandIassumeandunderstandallrisksinvolvedwiththeproceduresmypet
willreceive.
__________Ifaconditionisdiscoveredthatrequiresmedicalattentionorandadditionalproceduresuchas
theadministrationofintravenousfluidsormedications,theveterinarianmayinhis/herdiscretion,perform
suchprocedure.Iconsenttotheseproceduresandagreetopayanyreasonableadditionalcharges,ifany.
__________Iunderstandthatthemedicalstaffcanrefusetoperformanyprocedureonanyanimalforany
reason.Suchrefusalisatthesolediscretionoftheattendingveterinarian.
__________Iunderstandthatmyanimalwillreceiveasmalltattootoindicatehe/shehasbeensterilized.
__________Iunderstandthatmyanimalmustbepickedupfromtheshelteratthetimedesignatedbythe
staffonthedayofsurgery.IfIdonotclaimtheanimal,Iwillbechargedaboardingchargenotlessthan
$20/day.Iftheanimalisnotpickedupinthetimeaccordancewiththelaw,theanimalwillbeconsidered
abandonedandbecomepropertyoftheHornellAreaHumaneSocietyandIwillberesponsibleforboarding
chargesuntilthattime.
I,theowner/agentforthisanimal,understandthatthisisalegaldocument;havereaditcarefully;andfully
understanditscontent.Bymysignaturebelow,Igivemyinformedconsenttoallofitsterms.
Signature__________________________________________ Date__________________________
Pre-operativeInstructions
CANCELLATIONS
Weappreciateasmuchnoticeaspossibleifyouneedtocancelorrescheduleyourappointmentasweoftenhavea
waitinglistofanimalsinneedofourservices.Wehavereservedasurgicalslotforyou.Ifyouarenotabletokeepyour
appointment,pleaseletusknowASAP,(607)324-1270.
FEES
Allfeesaretobepaidwhenapplicationisturnedinaswellaseligibilityverification.Thisistobedonebeforean
appointmentwillbemade.A$20feewillbeassessedforcompletecancelationorlessthan24hournoticetoreschedule
appointment.Weacceptcash,creditordebitcards.NOPERSONALCHECKS.
VACCINATIONS
Foryourpet'sprotectionwerecommendcatshavetheirDistempervaccine(distemper-herpes-calicivirus)priortotheir
appointment.CatsanddogsarerequiredtohaveacurrentRabiesvaccination.Vaccinestaketwoweekstotakeeffect
soscheduleyoursurgeryatleasttwoweeksafterthevaccination.Ifyourpetisnotvaccinatedforrabies,wewill
vaccinateattimeofsurgery.
NIGHTBEFORESURGERY
1)Iftheanimalnormallystaysoutdoorsovernight,theymuststayindoorstheeveningbeforesurgery.
2)AnimalsoverfourmonthsoldMUSThavefoodandwaterwithdrawnatmidnightthenightbeforesurgery.This
ensuresthattheanimal'sstomachisemptybythetimetheyareputundergeneralanesthesia.Thislessensthechances
thattheanimalwillvomitandaspiratethevomitintotheirlungs.Ifyouradultpethaseatenonthemorningofsurgery,
wewillrefusetodosurgery.
3)Pediatricanimals(4monthsoryounger)shouldhaveasmallamountoffoodandwateravailableuntil6:00AMonthe
morningofsurgerythenitshouldbetakenaway.Thishelpstoavoidadecreasedbloodsugarlevel.
CHECK-INTIME
1)Wecheck-inallpatientsatthesametime–8:00am.
2)Wehaveaverystrictsurgicalschedulethatmustbefollowed.Itisveryimportantthatyouarriveontime.Ifyouare
latewemayneedtore-scheduleyourappointment.
3)Plantobehere20-30minutesinthemorning.
4)Whenyouarrivepleaseleaveyourpetinthecarandcomeinsidefirsttoassurethatallpaperworkisinorder.
5)Thevettechwillletyouknowwhentobringyourpetin.
Pleasenotethatintherareeventofunforeseencircumstancesoremergenciesattheclinictheremaybealongerwait
atcheck-inoryourpet’ssurgerymayneedtoberescheduled.
PRE-SURGERYEXAM
1)Ourveterinarianwillperformapre-operativephysicalexaminationtomakesurethatyourpetisagoodcandidatefor
surgery.
2)Ifyourpetistoofractioustohandle,aphysicalexamwillbeperformedunderanesthesia.
3)Feralcatsreceivetheirphysicalexamsunderanesthesia.
4)Ifyourpetshowssignsofillnessorifthereareanyconcerns(suchasage,aheartmurmur,severeupperrespiratory
infection,obesity,foodinstomach,etc.)wemayrefusesurgeryifwefeelsurgeryisahealthrisk.
WHATTOBRINGTOYOURAPPOINTMENT
1)Youmustpayforservicespriortoappointment.Weacceptcash,creditordebitcards.NOPERSONALCHECKS.
2)Catsmustbeinacleanpetcarriercommerciallymanufacturedforthepurposeoftransportingcatsandmusthavea
secureddoor,suchasahardplasticcarrieroracardboardcarrier.WeDONOTACCEPTanimalsinboxes,plastictotes,
laundrybaskets,orothernon-standardorhomemadedevices.
3)Donotputmultiplecatsinonecarrier.Yourpetneedstobeabletoliedowncomfortablyinthecarrieraftersurgery.
Yourpetmaybeagitatedoraggressivewhentheygohomeduetotheafter-effectsofanesthesia.Catsthatroutinelyget
alongwellmaynotbetolerantofeachotherintheimmediatepost-operativeperiod.
5)Ifyourcatisnotinapropercarrierasdescribedabove,acardboardcarrierwillbeprovidedtoyouatthecostof$5.
6)Ifyourpethascurrentvaccinationrecordspleasebringthemifyouhavenotprovidedthem.Ifyourpethasacurrent
rabiesvaccine,weneedtoseeproof(actualrabiescertificatenotrabiestagorlicense).
DISCHARGE
•Oncesurgicalproceduresarecompletedandafterfullrecoveryfromanesthesia,animalsaredischargedfromtheclinic
thesamedayassurgery.
•Catdischargeisfrom4:30-5:30pm.Youhavetheoptionofpickingupyourpetearlieriftheyareawakeenoughtogo
home.Inthiscasewewillcallyouatthenumberyouprovidewhenwefeelitissafetodischargeyourpet.
•Plantobehere20-30minutesfordischarge.Pleasenotethatintherareeventofunforeseencircumstancesor
emergenciesattheclinictheremaybealongerwaitatdischarge.
•Wewillreviewthepost-opinstructionswithyou.Youwillbetoldwhattoexpectoverthenextfewdaysasyourpet
recoversfromsurgery.
•Youwillbetoldofanyconditionsormedicalissuestheveterinarianmayhavefoundduringexaminationwhichmay
requirefollowupatafullserviceveterinaryclinic.
Youmustpickupyourpetasscheduledaswedonotboardpets.AnypetsleftovernightattheHornellAreaHumane
Societywillbechargedafeeof$20perdayandunclaimedpetswillbecomepropertyoftheshelteraspermittedbylaw.
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